Basic Information
| Provider Information | |||||||||
| NPI: | 1942305164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782844040 | ||||||||
| FaxNumber: | 6782844076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1357 HEMBREE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300765722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704757550 | ||||||||
| FaxNumber: | 7703439080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 021941 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000229809B | 05 | GA | MEDICAID |